GW1-2022-02841_Well Construction - GW1_20220228

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: -
:,Well Contractor Information:
CHRISTOPHER WATCHER
14.NVATER ZONES
Well Contractor Name FROM '1'O DESCRIPTION
4448A ft. ft. q q 0
NC Well Contractor Certification Number ft• fit. 13
15;OUTER;CASING,(fae multi-cased wells)OR LINER,if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. ft. 6 518 In. 188 G.STEEL
2.Well Construction Permit#: !let 1 S WIr t-(N%-1 16.INNER' SI. OR TUBING." eothermal closed-loo
TO
List all applicable we!!casstrerrlion permits(.c FROM DIAMETER THICAMOS MATERIAL
.U/C,County.State,Variance.err.) fit. ft. in.
3.Well Use(check well use): fit. ft. in.
Water Supply Well: 17'SCREEN
Agricultural FROM TO DIAMETER SLOTSI7.E THICKNESS MATERIAL[]Municipal/Public ft. ft. in.
11
Geothermal(Heating/Cooling Supply) ®'Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
hYi ation lS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft.
PORT.CEMENT POUR
:)Monitoring Recovery
Injection Well: et. tt.
Aquifer Recharge @Groundwater Remediation ft• ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENTMETHOD Aquifer Test �Stonnwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. tt.
Geothermal(Closed Loop) Tracer 2%DRILLING LOG attach addltional,sheets if necessary)
Geothermal(Heating/Cooling Return) 710ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock e. rain stye,etc.)
O ft. , ft. S o
�2Z- �
4.Date Well(s)Completed: Wcll ID# f. fL a � C
5a.Well Location: ft.
Facility/OwndName Facility ID#(ifapplicable) ft. fr.
StXW rwMus-,-1 r ft. ft.
Physical Address,City,and Zip ft ft
A—k04,`"-V ,t li I orl 14,74 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
O 22.Certiticatio
6.Is(are)the well(s)opermanent or 13Temporary Si tire o�fC•M i ell Contractor Date
B' mlf g this form,1 herehv certify that the we110)war(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or RJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lfe//Construction Standards and that a
1(this is a repair,fill out known well construction information and explain the native ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or at the back oJ'0us form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
(fit.)
For n,uh)ple we//s list a!/depths ifddere�u(example-3@200'and 2®/00') 24a. For All Wells: Submit this form within 30 days of completion of well
constriction to the following:
10.Static water level below top of casing:
(fwater(evel is above casing,use _ (ft.) Division of Water Resources,Information Processing Unit,
"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ROTARY above,also submit one copy of this!form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) constriction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Suoaly&IDjection Wells: In addition to sending the form to
13b.Disinfection q the address(es) above, also submit 'one copy of this form within 30 days of
ape: HTH Amount: `V Z completion of well construction to the county health department of the county
where constricted.
Forni GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016